Information Collection

Personal Injury Eligibility Form

IC 202767 under ICR 201201-1105-003 · OMB 1105-0092.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0092 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form XXXX Personal Injury Eligibility Form	Form and Instruction
XXXX Personal Injury Eligibility Form PI Eligibility Form FINAL 10272011 907PM.PDF	Form and Instruction

IC Title:

Personal Injury Eligibility Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	XXXX	Personal Injury Eligibility Form	PI Eligibility Form FINAL 10272011 907PM.PDF		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	31,500	31,500
Annual IC Time Burden (Hours)	94,500	94,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.